ELIMINATION DISORDERS:

Enuresis/Encopresis
DSM-IV
307.6 Enuresis (not due to a general medical condition)
307.7 Encopresis without constipation and overflow incontinence
787.6 Encopresis with constipation and overflow incontinence

The DSM-IV defines enuresis/encopresis as repeated involuntary (or, much more

rarely, intentional) voiding/passage of feces into places not appropriate for that
purpose, after attaining the developmental level at which continence is expected. If
continence has not been achieved, the condition can be termed “functional” or
“primary.” The period of continence necessary to differentiate between primary and
secondary enuresis/encopresis is now considered to be 1 year. There does seem to
be a significant relationship between enuresis and encopresis, although neither
condition can be the direct effect of a general medical condition (e.g., diabetes,
spina bifida, seizure activity) to be included in this category.

ETIOLOGICAL FACTORS
Psychodynamics
Numerous psychological interpretations exist speculating on the dynamics of
toilet training and the significance of flushing bodily fluids down the toilet. Freudian
theory places the fixation at the anal stage of development whereby the child fails
to neutralize libidinal urges, and the aggressive impulses are fused with the pleasure
of controlling bodily functions. Expulsion of feces or urination and untimed feces or
urination or intentionally placing the feces in inappropriate places elicits hostility
from parents. Loss of bodily functions leads to loss of self-respect, loss of friends,
and feelings of shame and isolation.

Biological
Learning to control urination/defecation is a developmental task most likely
achieved by age 4 or 5 and requires a mechanically effective anatomy. In some
enuretic children, abnormalities in regulation of vasopressor/antidiuretic hormone
(ADH) have been evidenced, with ADH regulation being linked to both the
dopaminergic and serotonergic systems. A theory of developmental delay suggests
there is a common underlying maturational factor that predisposes children to
manifest both enuresis and behavioral disturbances. Enuresis and encopresis are
normal responses to environmental stresses that occur in certain situations (e.g.,
when a child is separated from his or her family or is abused). In either case, as the
child matures and the environmental stressors are alleviated, normal bodily control
is resumed. Children who are hyperactive may have occasional accidents, as they do
not attend to the sensory stimuli until it is too late.
Enuresis and its relationship to bladder capacity and urinary tract infections has
been explored, as has nocturnal enuresis occurring during deep sleep with no
response to arousal signals. In addition, research has been conducted to investigate
the physiological basis for encopresis. These studies indicate that the act of bearing
down led to decreased anal sphincter control in almost all cases.
Soiling may result from excessive fluid buildup caused by diarrhea, anxiety, or
the retention overflow process, whereby leakage occurs around a retentive fecal
mass. This mechanism is responsible for 75% of encopretic children.
 Genetically, a child is at risk for enuresis if the parent has a history of enuresis
after the age of 4. Recent research suggests a genetic mutation on chromosome 13.

Family Dynamics
As mentioned previously, the parental attitude toward cleanliness and the
rigidity with which this behavior is controlled may perpetuate the fear associated
with loss of bodily control. Parents often get caught up in the volitional aspects,
blaming the child for “acting like a baby.” Further social embarrassment ensues
when school personnel target the problem in terms of “the dirty child from a dirty
family.” Attempts to deny the problem lead to covert behaviors such as hiding soiled
clothing in lockers, under the bed, or in the trash. The child may in fact be using the
only weapon available, as in the case of severe neglect and/or sexual assault.

CLIENT ASSESSMENT DATABASE

Activity/Rest
May/may not be awakened when bed-wetting occurs
Unusual sleep habits, increased incidence of sleepwalking or sleep terror disorders

Ego Integrity
Expressions of poor self-esteem (e.g., “I am bad”)
Shy, withdrawn, feelings of isolation, shame
Overly anxious around adult figures
Stressors may include family conflicts/change in structure (e.g., divorce, birth of a
sibling)

Elimination
History of delayed or difficult toilet training
Inattention to cues of need for elimination
Episodes of urinary incontinence twice a week for at least 3 consecutive months in
child of at least 5 years of age (or equivalent developmental level)
Pattern of diurnal and/or nocturnal enuresis
One episode of soiling per month over a 3-month period in child at least 4 years of
age (or equivalent developmental level)
Fecal incontinence; seepage secondary to fecal retention/colorectal loading
Anal self-stimulation may be noted in nocturnal pattern of soiling

Hygiene
Deliberate attempts to hide evidence of soiled clothing

Neurosensory
May have developmental (neuromuscular or gross motor) delays
Less than 1/3 of enuretic children have documented emotional disorders (regression
is rarely reason for problem)
Acting-out behaviors (e.g., placing feces or defecating in inappropriate places for
retaliation)

Safety
 History/evidence of abuse may be present (condition may be related to abuse and/or
the cause of abuse)

Sexuality
Avoidance of sexual activity in older adolescents

Social Interactions
Impaired social, academic functioning
Power struggles with family/school to maintain personal hygiene, change bed linens
Reluctance to engage in peer activities; social rejection (body odor)
Uncomfortable spending the night with friends either in own home or away

Teaching/Learning
Usual age of onset 5–7 years, developmental age of at least 4 (encopresis) or 5
(enuresis) years
Prevalence as high as 22% of 5-year-olds, 10% of 10-year-olds
Boys more often affected than girls (3:1)
History of parental enuresis
Bed-wetting suppressed only as long as medication is taken; relapse usually
occurring within 3 months

DIAGNOSTIC STUDIES
Urinalysis: Rule out UTI.
Electrolytes: Identify imbalance in presence of chronic diarrhea.
Abdominal, Lower GI X-Rays: Evaluate anatomical abnormalities such as anal
fissure, obstruction.
Cystometrogram (CMG): Test for bladder capacity when in question.
Detailed Toilet Training History: Baseline continence data clarifying problem and
evaluating for secondary vs. primary enuresis/encopresis.
ECG: To provide baseline when starting antidepressant medication.

NURSING PRIORITIES
1. Promote understanding of condition.
2. Identify and support change in parent/child patterns of interaction.
3. Enhance self-esteem.
4. Assist client in achieving continence.

DISCHARGE GOALS
1. Condition/therapy needs are understood.
2. All parties are participating in therapeutic regimen.
3. Achieves as near a normal pattern of bowel/bladder functioning as individually
possible.
4. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS URINARY ELIMINATION, altered/

BOWEL incontinence
 May Be Related to: Situational/maturational crisis
Psychogenic factors: predisposing vulnerability;
threat to physical integrity (child/sexual abuse)
Constipation
Possibly Evidenced by: Nocturnal and/or diurnal enuresis
Involuntary passage of stool at least once
monthly
Strong odor of urine/feces on client
Hiding fecal material/soiled clothing in
inappropriate places
Desired Outcomes/Evaluation Criteria— Verbalize understanding of contributing factors
Client/Family Will: and appropriate interventions.
Participate in appropriate toileting program.
Client Will: Achieve continence.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Identify times of occurrence, preceding/precipitating Baseline data will help identify patterns
and
events, amounts of oral fluids, and family/client document improvement after treatment begins
response to incontinence.
Check for fecal impaction. This may be a contributing factor.
Discuss measures client/family have tried and Typically, parents/caregivers have tried various
successes/failures to date. methods, usually getting child up periodically at
night, limiting fluids before bedtime, and having
older children change soiled bed linens. These
methods are not very effective and usually lead
to
frustration, power struggles/battles.
Suggest use of bladder-stretching exercises (e.g., ask Although this method can have good
results, the
child to drink favorite beverage and wait to urinate length of time needed may be
discouraging and
until the urge becomes very strong, then measure the result in the family discontinuing the
program.
amount of urine voided). Gradually increase amount
of liquid and waiting period.
Discuss use of conditioning programs and ask The use of conditioning therapy and/or behavior
parents/caregivers to maintain a record of modification usually does not begin until the
child
occurrences for a specified period before either is age 7 or older. The child needs to make a com-
program begins. mitment to be involved for the program to
succeed.
Information regarding the current individual
pattern provides a baseline for future evaluation.
Instruct client/family in use of electronic nighttime Urine alarms (e.g., Wet-Stop) have an
effective cure
monitoring device (bell and pad). rate of 75% to 90%. Once treatment is started,
the
alarm should be used every night.
Instruct parents/caregiver initially to get child up Client may be fearful at first because of previous
each time the urine alarm buzzer sounds, shifting family interactions. In the beginning, the
parents
the responsibility gradually to child by stating, will probably awaken before the child and take
the
“I want you to know you can do this all by yourself.” child to the bathroom. However, as the
program
Keep a record of how often the alarm sounds and progresses, the child will awaken more
quickly
how sound the child’s sleep is. and assume control. Empowerment promotes
feelings of being in control.
Active-listen and involve client in developing the Establishing a plan to which the client agrees has

plan for remaining dry/clean. Institute a system of more chance of success than using
aversive
positive reinforcement. Use rewards that the child operant behavioral interventions (e.g.,
bell alarm)
would like or agrees to. Use the previously alone. Behavioral therapy may be useful when
determined baseline data to determine parameters client is included in the planning, with
rewards,
of the reward system and when to increase schedule. such as tokens having value, if client
agrees to
their use. Note: If client is not involved in
planning/vested in behavioral program, then
therapy becomes an external control
manipulating
the client rather than promoting internal control
and growth.
Establish toileting routine with positive Client may begin to establish bowel/bladder
reinforcement for “sitting time” and depositing habits often missing prior to treatment.
urine/feces in lavatory appropriately.
Treat occasional relapses with matter-of-fact Relapse (whether intentional or not) is to be
attitude and follow through with procedures for expected but may be minimized when the client
self-hygiene. does not feel pressured/blamed for lack of
cooperation.
Discuss length of treatment with parents/client and Knowing that treatment is ongoing
prevents
make plans for maintaining dry/clean status. becoming discouraged and giving up
treatment.

Collaborative
Administer medications as appropriate, e.g:
Imipramine (Tofranil); May be used after age 7 for enuresis. However,
drug therapy is only a temporary treatment, not
a
cure, as condition recurs within 3 months after
medication is discontinued. Pharmacological
studies indicate improvement in encopresis with
relatively low doses over 2-week period. Note:
Factors such as child’s age, duration of problem,
and child’s motivation to change are factors that
affect decision to include pharmacological
agents
in combination with behavioral interventions.
Desmopressin acetate (DDAVP); Used for enuresis that has been intractable to
other
approaches.
Amphetamines; These drugs lighten sleep; therefore, client is
more
likely to awaken to arousal signals.
Laxatives and/or mineral oil. Given daily for a specific period of time, these
agents may promote bowel motility, ease
evacuation of stool.
Refer for evaluation of other therapies (e.g., Used alone or in conjunction with conditioning,
hypnotherapy). the use of hypnosis can help the child access the
subconscious mind allowing the child to work
through emotional conflicts and develop positive
suggestions that he or she has good muscle control

and will be dry in the morning. Note: This

technique
is contraindicated in the presence of child abuse.

NURSING DIAGNOSIS BODY IMAGE disturbance/SELF ESTEEM,

May Be Related to:
Possibly Evidenced by:
Desired Outcomes/Evaluation Criteria—
chronic low
Negative view of the self, maturational
expectations
Social factors; stigma attached to loss of bodily
functions in public
Family’s belief that soiling/ enuresis is volitional
Shame related to body odor
Angry outbursts/oppositional behavior
Verbalization of powerlessness to change/control
bodily functions
Reluctance to take social risks with friends (e.g.,
overnights, dancing)
Verbalize acceptance of self in situation.
 Client Will: Acknowledge own responsibility and control over
situation.
Participate in treatment program to effect
change.
Engage in social activities.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Establish a therapeutic nurse/client relationship. Within a helping relationship, the individual will
begin to trust and try out new thinking and
behaviors.
Promote self-concept without moral judgment by use Individual may see self as weak, even
though he
of therapeutic communication skills. Discuss how or she acts as if in control. Age-
appropriate
elimination habits are formed and fact that new information can help the child/family understand
habits can be learned. there is nothing wrong with the child and the
problem can be solved.
Explain to child/family that many children have this There is an increased risk for poor self-
esteem/
problem. Suggest stories child can read (e.g., Clouds isolation when client views self as being
“the only
and Clock, by M. Galvin [1989]). one.” Use of bibliotherapy can help child to
identify with others.
Promote active problem-solving and self-hygiene Gives sense of control, supports ability to
behaviors around some of the disagreeable aspects overcome stigma, enhancing self-esteem.
of enuresis/encopresis (e.g., control of odor,
management of laundry, and successful overnight
visits with friends).
Be aware of own reaction to client’s behavior. Feelings of disgust, hostility, and wanting
distance
Avoid controlling attitude or arguing with child from these clients are not uncommon. The child
about hygiene or toileting routine. may in fact be projecting his or her own negative

feelings onto the caretaker. The nurse needs to

deal with own responses/feelings to avoid having

them interfere with care of the child.

Give positive reinforcement and encouragement for Promotes repetition of desired behaviors,
all attempts to join in peer activities or take additional strengthens client’s willingness to change,
and
risks in social situations. enhances self-esteem.
 NURSING DIAGNOSIS FAMILY COPING: ineffective (specify)
May Be Related to: Inadequate/incorrect information or
understanding by primary person; belief that
behavior is volitional
Disagreement regarding treatment, coping
strategies
Possibly Evidenced by: Attempts to intervene with child are increasingly
ineffective
Significant person describes preoccupation with
personal reaction (excessive guilt, anger, blame
regarding child’s condition/behavior)
Significant person displays protective behavior
disproportionate (too little or too much) to
client’s abilities or need for autonomy
Desired Outcomes/Evaluation Criteria— Express feelings openly and honestly.
Family Will: Identify resources within self to deal with
situation.
Desired Outcomes/Evaluation Criteria— Verbalize realistic understanding and
expectations
Family Will (cont.): of client.
Provide opportunity for client to deal with
situation in own way, as appropriate.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Identify behaviors of/interactions between family Withdrawal, anger/hostility toward
client/others,
members. ways of touching among family members, and
expressions of guilt provide clues to problems
within family related to or contributing to
problem.
Assess for signs of child/sexual abuse. These issues may be contributing factors to this
problem. (Refer to CP: Problems Related to Abuse

or Neglect.)
Note verbal/nonverbal expressions of frustration, Problems of enuresis/encopresis are difficult for
guilt/blame. family members to deal with because of the
long-
term aspect of the problem. More support may
be
needed to deal with high level of frustration.
Determine willingness of family members to be Success of any program depends on all members

involved in treatment program. being positively committed to therapy.

Uncommitted members may sabotage the
program.
Encourage expression of feelings openly and honestly. Feelings of frustration and fear are
common and,
unless discussed, can interfere with progress of
therapy.
Discuss with the parents/caregivers the importance Effective use of “win-win” methods (e.g.,
Active-
of being neither too strict nor too permissive in listening, I-messages, and problem-solving) can
dealing with this problem. enhance the parent/child relationship and
promote good feelings about selves and others.
(Refer to CP: Parenting.)
Recommend avoidance of spanking or other The use of harsh discipline usually results in
harsh punishment. power struggles where no one wins, making the
problem worse and damaging the relationship
between adult and child.
Help parents recognize they are not responsible for, Parents often believe they have been
“bad” parents
and need to separate themselves from, the child’s and are responsible for the child’s failure
to
behavior. achieve what they view as a “natural” behavior.
When they see the child as a separate individual
who has responsibility for own self, they can let
go
and be more comfortable in resolving the
problem.